Primary care pharmacists are still explaining what structured medication reviews are for
Structured medication reviews, or SMRs, were introduced into English primary care in 2020 with a clear remit: identify medicines-related harm, optimise prescribing, and support patients living with multiple long-term conditions, polypharmacy, frailty, or residence in care homes. In practice, the work has proved more complicated than the policy wording suggests. Clinical pharmacists and SMR service leaders described a service that many patients had never been properly prepared for, leaving pharmacists to spend valuable consultation time explaining the purpose of the review before the real clinical discussion could begin.
Eighteen clinical pharmacists and five SMR leads took part in qualitative one-to-one interviews conducted in England between February 2023 and November 2024. Their accounts point to a service that is widely valued by clinicians, yet unevenly absorbed into day-to-day primary care. The interviews were structured around normalisation process theory, a framework designed to examine how new practices become embedded in routine work. In this case, the framework fit the problem well: the central issue was not whether SMRs were worthwhile, but how they could become a dependable part of care rather than an added task competing with everything else already in primary care.
Patients arrived with uneven expectations. Some had not been told in advance that an SMR was scheduled, and some did not understand why a pharmacist, rather than a doctor, was leading the conversation. That uncertainty mattered at the bedside. A review that begins with explanation instead of shared decision-making loses time, and in medication management, time is often the difference between a generic checklist and a meaningful clinical intervention. When patients understood the process, pharmacists reported that trust developed more quickly and the consultation became more useful for uncovering adherence problems, adverse effects, duplicate therapy, or untreated symptoms that had been quietly absorbed into daily life.
Workload, staffing, and leadership determine whether SMRs reach the right patients
The interviews show a service whose success depends heavily on local conditions. High workload repeatedly surfaced as a barrier, and the pressure did not stop with pharmacists. Inadequate administrative support and insufficient pharmacist technician resource left some teams unable to organise reviews efficiently or prepare them to a standard that made the clinical encounter flow. Where leadership support was inconsistent, SMRs were more likely to feel like an extra deliverable than a coordinated care function.
Integration varied from one setting to another because implementation was uneven, not because the intervention lacked clinical value. Pharmacists described the challenge of carving out enough time to review complex medication lists, interpret prescribing histories, and address problems that often stretched across multiple long-term conditions. In patients with multiple long-term conditions, polypharmacy is rarely a simple counting exercise. The clinical task is to weigh benefit against cumulative burden, detect drug-disease interactions, identify medicines that no longer match patient goals, and decide when simplification is safer than escalation. That kind of work is only feasible when there is protected time, clear role definition, and administrative machinery that does not collapse under routine demand.
One blunt reality emerged from the interviews: a service built to improve medicines use can be diluted if the people delivering it are left to explain its purpose, find the right patients, and manage the logistics alone.
Consultation skill and patient trust shape the quality of deprescribing decisions
Pharmacists consistently valued SMRs as a way to identify unmet need and support more person-centred care across pathways for people with multimorbidity. Their descriptions suggest that the benefit of an SMR is not limited to stopping medicines. The process also creates room to revisit whether each drug still fits the patient’s symptoms, function, frailty, and treatment priorities. In older adults or those with complex chronic disease, that broader conversation can expose problems that would remain hidden in a shorter, prescription-focused review.
The interviews place consultation skill at the center of optimisation. Tailoring the conversation to the individual patient was described as essential, and that is clinically sensible. A structured medication review is not a protocol to be read aloud; it is a negotiated appraisal of risk, benefit, burden, and lived experience. If the consultation is rushed or overly formulaic, the chance to uncover side effects, confusion about indications, or practical barriers to adherence drops quickly. If trust is established, the review becomes more likely to surface issues that can be acted on safely, whether that means dose adjustment, simplification, or stopping unnecessary treatment.
Normalisation process theory helped clarify why some SMRs became routine while others remained fragmented. When patients were not informed, when staffing was thin, or when teams lacked training in consultation technique, the service struggled to settle into everyday practice. The pattern is unsurprising in primary care, where new responsibilities often fail not because they are clinically unsound, but because they are layered onto systems already operating near capacity. SMRs ask for coordination across reception, administration, pharmacy, and clinical decision-making. If one part of that chain is weak, the whole service slows.
The study points to a practical sequence for improving SMRs: patients need clearer information before appointments, primary care teams need a better shared understanding of what the service is meant to achieve, and pharmacists need time and training to conduct consultations that can handle complexity without becoming mechanical. Without those supports, SMRs risk remaining a well-intentioned intervention that is admired in principle but inconsistently delivered in practice. The main unresolved issue is operational rather than conceptual: how to build enough capacity, communication, and clinical confidence for the service to function reliably across ordinary primary care workloads.